The following documents were collected from electronic medical records on March 7, 2024. When the records were checked again the following week, on March 14, 2024, these documents could not be found. A call placed on March 15 was met with confusion, as hospital administration insisted that the documents in question had never existed in their electronic medical records. As a result, the events described here now only exist as part of the following transcript.

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The names and identifying information of all parties involved have been changed for privacy.

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Name: John Berg
MRN: XXXXXXXXXXXX

Date: 01/03/24
Time: 9:00 A.M.

Reason for Visit: New Patient

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History of Present Illness:
37 y.o. right-handed male with no significant prior medical or surgical history, presenting with two days of right-hand pain and sensitivity in the distribution of the first through third digits. Pain is currently localized to the hand alone and does not radiate up the wrist. Patient denies any other symptoms or an inciting incident for his pain, but the sudden appearance of his condition on New Year’s Day and his appearance in clinic indicate that Mr. Berg may have had too good of a time on New Year’s Eve. When asked, Mr. Berg denied any such activities on the night in question, although I reminded him that memory is usually impaired by inebriation. Mr. Berg insists that on New Year’s Eve, he went out early, stopped for a beer at his local bar at six o’clock, then left after drinking only half of his pint, at six-thirty. When pressed, the patient denied using any other substances on the evening in question, and his medical record does not reflect any prescription medications. However, I remain skeptical of these assertions at this time. 

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Physical Examination:
BP: 127/84
Pulse: 66
Temp: 97.8 °F (36.6 °C)

General: Poor appearance (disheveled, unshaven, wearing a hat and ratty clothes), well developed, (very) well-nourished, appears stated age
Mental Status: Low intelligence, fixated, argumentative, disagreeable, otherwise awake, alert, interactive, and oriented to self/city/year
Cranial Nerves: Extraocular movements intact, visual acuity normal, face symmetric, tongue midline, shoulder shrug symmetric
Motor: 4/5 strength in right hand (grip, extension, flexion), 5/5 strength in all other extremities
Sensory: Claims reduced sensation and sensitivity to touch without erythema or swelling in the right palm, median nerve distribution, all other sensory distributions normal
Gait: Stable, steady
Coordination: Bilateral finger to nose with no dysmetria
Reflexes: No Hoffman’s, no clonus, no hyperreflexia 

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Labs:
No labs required or ordered at this time.

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Imaging:
No prior imaging. No future imaging required or ordered at this time.

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Assessment:
37 y.o. right-handed male presenting with pain and numbness of the right hand in the distribution of the first through third digits, without radiation into the wrist. Denies other symptoms, although patient is most likely an unreliable historian and should be treated as such in future visits. Most likely cause of pain is a drunken accident which the patient has forgotten due to his inebriation on New Year’s Eve.

Exam concurs with my diagnosis.

I assured the patient that his pain would subside in the coming days and advised him to use an anti-inflammatory if the issue worsened. I then lightly reprimanded him for his lack of cognizance and memory regarding his injury, at which point he became unreasonable and argumentative, declaring that he had not injured himself (in spite of the evidence to the contrary). I asked the patient to regain his composure, and when he had done so, reminded him of my expertise, which was why he had come to see me. At this, the patient became much more cooperative and listened more closely to my instructions. At the end of our visit, I wished the patient a pleasant day. 

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Plan:
-Patient will self-manage pain with usual remedies
-No need for follow-up in clinic

 

William J. Mercer, MD
Physical Medicine and Rehabilitation
Brown Medical School | Rhode Island Hospital 

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Name: John Berg
MRN: XXXXXXXXXXXX

Date: 01/10/24
Time: 10:15 A.M.

Reason for Visit: Follow-up appointment for self-inflicted injury

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History of Present Illness:
37 y.o. right-handed male previously seen in clinic on 1/03/24 for several days of right-hand pain and sensitivity in the distribution of digits one through three, the result of a drunken incident on New Year’s Eve. Although there was no prior radiation into the wrist, the patient now claims that his hand pain has not only worsened, but “spread” up his right arm to a point just past elbow, proximal to the shoulder. In addition to these incredibly unlikely symptoms, the patient states that he is suffering from persistent headaches and a ringing in his ears. When informed that these symptoms were almost certainly distinct from his hand pain, the patient winced, closed his eyes, and bowed his head forward. After waiting a moment, I asked the patient if he was still with me. The patient opened his eyes and raised his head back towards me. I then asked him if he was still drinking heavily, to which the patient responded by claiming that he had never been a heavy drinker. Unfortunately, in this case, we must disregard the patient’s self-reporting, for several reasons. I inquired into one of these reasons by asking the patient whether he was currently employed. He said that he was. When asked his occupation, he stated construction, and when asked if he was pursuing workers’ compensation at this time, he denied any such actions on his part. Again, I am suspicious of the patient’s motives for coming into clinic today and am concerned that he is attempting to pursue a fraudulent worker’s compensation case. 

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Physical Examination:
BP: 134/91
Pulse: 68
Temp: 98.2 °F (36.7 °C)

General: Poor appearance (unimproved since last visit), well developed, (very) well-nourished, appears stated age
Mental Status: Low intelligence unchanged, has become MORE fixated, argumentative, and disagreeable in regards to his “condition,” sometimes distracted by the “ringing” in his ears, otherwise awake, alert, interactive, and oriented to self/city/year
Cranial Nerves: Extraocular movements intact, visual acuity normal, face symmetric, tongue midline, shoulder shrug symmetric
Motor: 4/5 strength in right hand (grip, extension, flexion) and arm (extension, flexion), 5/5 strength in all other extremities
Sensory: Claims reduced sensation and sensitivity to touch without erythema or swelling in the right palm, median nerve distribution, sensation decreased on right arm as compared to left all other sensory distributions normal
Gait: Stable, steady
Coordination: Bilateral finger to nose with no dysmetria
Reflexes: No Hoffman’s, no clonus, no hyperreflexia 

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Labs:
I still see no need for labs at this time.

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Imaging:
I see no need for imaging.

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Assessment:
37 y.o. right-handed male presenting with self-described pain and numbness of the right hand in the distribution of the first through third digits, with radiation up from the wrist into the upper arm, just below the shoulder. Patient also claims ringing in the ears and headache as associated symptoms. Patient is most certainly an unreliable historian at this point, and his chart will be made to reflect this status moving forward with all of our care providers. It is very likely that these symptoms are entirely fabricated by the patient, perhaps in the hope of obtaining workers’ compensation for an injury which was actually sustained off of his job site.

Exam concurs with my diagnosis.

I once again assured the patient that his pain would subside in the coming days and advised him to use an anti-inflammatory if the issue worsened. I attempted to gently dissuade the patient from any fraudulent compensation claims by discussing the pitfalls of such practice in general, but the patient did not appear to pay close attention to my advice. He was consistently distracted, and at one point during our discussion, his eyes widened as he was looking over my shoulder. When I asked what was wrong, the patient did not respond. For a moment, he simply remained fixated on the point over my shoulder, his face falling into a strange, twisted expression. When I asked again what was the matter, the patient finally met my gaze, sweat beading on his forehead. He assured me that nothing was the matter, that he had merely been distracted. I advised the patient that incurring expensive medical bills with recurrent visits to our clinic was something to be best avoided, especially for benign symptoms such as his. At the end of our visit, I wished the patient a pleasant day.

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Plan:
-Patient will self-manage pain with usual remedies
-No need for follow-up in clinic

 

William J. Mercer, MD
Physical Medicine and Rehabilitation
Brown Medical School | Rhode Island Hospital

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Name: John Berg
MRN: XXXXXXXXXXXX

Date: 01/27/24
Time: 8:00 A.M.

Reason for Visit: Unnecessary Follow-Up

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History of Present Illness:
37 y.o. right-handed male previously seen in clinic on 1/10/24 for imagined pain and numbness in the right hand and right arm, most likely conceived in an effort to secure workers’ compensation for an injury not sustained at the patient’s job site. Patient presents today with his wife, who was the primary historian during the encounter. Unfortunately, she is just as unreliable as her husband and appears to be an equal party in their attempted fraud. It will be noted in the patient’s chart that her statements should likewise be disregarded at all future visits. Patient presented with self-applied bandages on his right hand and arm and did not respond to my greeting. He did not make eye contact, but instead took to staring towards one corner of the room, first as his wife guided him to his seat, then as she spoke. At several points during our discussion, the patient would press his hands against his ears and close his eyes, as though he were attempting to drown out some loud noise or voice that he was hearing. I found the tenor of his wife’s voice equally disquieting. She insulted both my expertise and my professional assessment of her husband’s condition, stating that I had no knowledge of how to treat a human being. When I reminded her that I had been treating human beings for over fifteen years with great success, she removed the bandages form her husband’s right hand and arm and showed me a series of grievous wounds gouged into his skin. Pale, pulsating tissue and muscle was clearly visible through the torn flesh of the patient’s palm, forearm, and upper arm. The wounds were lacerations, in the same distribution as a rash or pox, and appeared to have been made by fingernails clawing through the skin. I have never before seen such a terrible display of self-mutilation, nor have I ever seen such a disturbing complexion in human viscera. After taking a moment to collect my thoughts, I asked the patient’s wife who was responsible for her husband’s injuries. The patient’s wife shook her head and insisted that no one had so much as touched her husband in the five days since the wounds appeared on his skin. This all but confirmed my suspicions of a conspiracy between the patient and his wife in order to commit some kind of fraud. However, the wounds demonstrated that there was a real danger, for if this man was willing to harm his own body, he would certainly have no issue in harming mine. Telling the patient that I needed to confer with my colleague about his condition, I quickly left the room and had the front desk phone security. Two officers were immediately summoned and escorted the patient and his wife from the examination room and the building. The patient’s wife was quite belligerent, casting wild aspersions and threats at myself and the members of security as she left. The patient himself made no argument. He did, however, pause as he left. He raised his eyes towards me for the first time in the course of our visit, and I saw that he had a bloodshot gaze. Although it only lasted a moment, I was nevertheless quite unnerved by the way he stared insistently at me. 

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Physical Examination:
BP: 150/100
Pulse: 87
Temp: 100.2 °F (37.8 °C)

No further examination performed.

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Labs:
I order no labs at this time.

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Imaging:
I order no imaging for this patient.

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Assessment:
37 y.o. RHM presenting with superficial self-inflicted lacerations extending from the right hand to a point midway up the right arm, above the elbow. Patient has a history of drunkenness, belligerence, and fraud, beginning from his first visit onward. I have informed hospital administration that this patient is no longer welcome at my clinic and will not be seen by me in the future, out of concern for the safety of myself and my staff. I am attempting to extend this same precaution to the patient’s wife, who has left me several messages in the days since our encounter, all of which are hostile in nature. 

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I did not wish the patient a pleasant day at the end of our visit.

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Plan:
-Preclude the patient’s return
-Attempt to preclude his wife’s return

 

William J. Mercer, MD
Physical Medicine and Rehabilitation
Brown Medical School | Rhode Island Hospital

 

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Date: 02/13/24
Time: 8:30 P.M.

Mr. Berg came to see me today. When all the staff had gone, and there were no more patients to be found in the empty, quiet chairs of the waiting room, when the gloom had settled after sunset and the electric lights were dim, I walked by a door that should have been locked and shut. It was dark inside, and I had just reached in to close the door, when I heard a voice speak out from the room. It was Mr. Berg’s voice, quiet and subdued, and my hand froze on the knob at his words. He asked me to come in. Slowly, I pushed the door inward, towards the sound of his voice, though I could not see him in the darkness of the room. I reached for the switch on the wall and felt it click under my hand, back and forth, as the lights refused to come on. Mr. Berg asked if I would come closer, and without thought, my legs brought me deeper into that dark room, where I could see nothing. Mr. Berg asked me if I thought I was a good man. I did not reply. He then asked if I had a family. I said that I had a wife and two daughters. I still could not see Mr. Berg, but I heard a creak from the corner of the room, the sound of someone rising to their feet and walking across the tiled floor. His voice was much closer when he asked to shake my hand. There was a cold sweat on the back of my neck. Trembling, I reached my right hand out towards nothing, and though I saw only darkness, I felt a cold grip around my fingers, sinking into my skin. When it was over, I waited for something more. I stood in the dark and strained my ears, but could hear nothing further. I called out for Mr. Berg, and was met with silence.

 

William J. Mercer, MD
Physical Medicine and Rehabilitation
Brown Medical School | Rhode Island Hospital

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Death Notice

 

Patient Name: Mr. John Berg MRN: XXXXXXXXXXXX
Patient Gender: Male Patient Date of Birth: September 9, 1986
Date of Death: February 13, 2024 Time of Death: 06:26 P.M.

 

This is to certify that the above patient passed away at the date and time specified above due to extensive, debilitating necrosis of the tissues and muscles of the extremities, thorax, heart, neck, face, and brain. 

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The patient was admitted into the hospital on February 13, 2024, at 6:13 P.M. with the aforementioned injuries. Patient immediately entered into convulsions upon his arrival and was restrained as he began to foam and bleed at the mouth, having bit his own tongue. The skin on either side of the patient’s mouth had degraded to the point that blood and saliva freely flowed out over the patient’s body and onto his hospital bed. Other wounds were discovered on the patient’s body, consistent with the appearance of scratches and claw marks, which likewise bled continuously throughout his treatment. Sedation was attempted but proved unsuccessful. Intravenous antibiotics and antivirals were administered. Shortly after the patient’s arrival, his convulsions reached their peak, as the patient strained with such force against his restraints that they cut into his own skin. By 6:37 p.m., Mr. Berg’s heart was no longer beating, and he was pronounced dead.  

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On autopsy, no true pathogen was found in any of the patient’s wounds. It is unknown what specific microbe or underlying condition could have led to the patient’s extensive injuries, especially in such a short course of time.

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The patient’s wife, Mrs. Caroline Berg, was present with her husband at the time of his passing.

 

Signed:

 

Dr. Nathaniel Pendel
Attending Surgeon
Rhode Island Hospital Emergency Department
February 16, 2024

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Name: William Mercer
MRN: XXXXXXXXXXXX

Date: 02/20/24
Time: 9:00 A.M.

Reason for Visit: New Patient

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History of Present Illness:
48 y.o. right-handed male with no significant prior medical or surgical history, presenting with a week of right-hand pain and sensitivity in the distribution of the first through third digits. Pain is currently localized to the hand alone and does not radiate up the wrist. Patient denies any other symptoms or an inciting incident for his pain. When asked about his recent alcohol consumption, patient became indignant and unresponsive.  

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Physical Examination:
BP: 132/90
Pulse: 74
Temp: 97.7 °F (36.6 °C)

General: Poor appearance (disheveled, unshaven), well developed, (very) well-nourished, appears stated age
Mental Status: Argumentative, disagreeable, fixated, otherwise awake, alert, interactive, and oriented to self/city/year
Cranial Nerves: Extraocular movements intact, visual acuity normal, face symmetric, tongue midline, shoulder shrug symmetric
Motor: 4/5 strength in right hand (grip, extension, flexion), 5/5 strength in all other extremities
Sensory: Claims reduced sensation and sensitivity to touch without erythema or swelling in the right palm, median nerve distribution, all other sensory distributions normal
Gait: Stable, steady
Coordination: Bilateral finger to nose with no dysmetria
Reflexes: No Hoffman’s, no clonus, no hyperreflexia 

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Labs:
No labs required or ordered at this time.

​

Imaging:
No prior imaging. No future imaging required or ordered at this time.

​

Assessment:
48 y.o. RHM presenting with pain and numbness of the right hand in the distribution of the first through third digits, without radiation into the wrist. Denies other symptoms, although patient would not disclose his pattern of alcohol consumption. Most likely, this is an accidental injury or over-exertion, consistent with the patient’s age.

Exam concurs with my diagnosis.

I assured the patient that his pain would subside in the coming days and advised him to use an anti-inflammatory if the issue worsened. The patient became incensed and demanded that I provide him with a better explanation than routine pain. I then asked the patient to regain his composure and reminded him of my expertise, which was why he had come to see me in the first place. At this, the patient became silent, and I was able to finish giving him my opinion. At the end of our visit, I wished the patient a pleasant day, and he left without complaint.

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Plan:
-Patient will self-manage pain with usual remedies
-No need for follow-up in clinic

Philip R. Donnelly, MD
Physical Medicine and Rehabilitation
Newport Hospital